pcos presentation
TRANSCRIPT
Markers and Interventions for Nonobese Women with Polycystic
Ovarian SyndromeZoë Wasserman
What is Polycystic Ovarian Syndrome?
What is Polycystic Ovarian Syndrome?
Polycystic Ovaries Hyperandrogenism
Infrequent/Absent menses
What is Polycystic Ovarian Syndrome?
Polycystic Ovaries Hyperandrogenism
Infrequent/Absent menses
5-6 Million Reproductive Age American Women
What is Polycystic Ovarian Syndrome?
Polycystic Ovaries Hyperandrogenism
Infrequent/Absent menses
5-6 Million Reproductive Age American Women
Exclusionary Diagnosis
PCOS = Exclusionary DiagnosisCongenital Adrenal Hyperplasia
PCOS = Exclusionary DiagnosisCongenital Adrenal Hyperplasia
Adrenal Tumor
PCOS = Exclusionary DiagnosisCongenital Adrenal Hyperplasia
Hypothyroidism:Low Production of Thyroid HormoneAdrenal Tumor
PCOS = Exclusionary DiagnosisCongenital Adrenal Hyperplasia
Cushing Syndrome:Excessive Cortisol Production
Hypothyroidism:Low Production of Thyroid HormoneAdrenal Tumor
Rotterdam Criteria: Hyperandrogenism>80% cases
Roe & Dokras, (2011).
Rotterdam Criteria: Oligo-Anovulation
(Roe & Dokras, 2011).
Rotterdam Criteria: Oligo-Anovulation
→ Earliest Clinical Sign
→ ~ 6-8 week cycles
→ 75% cases(Roe & Dokras, 2011).
Rotterdam criteria: polycystic ovaries
PCOS Phenotypes● Obese vs Nonobese (overweight, normal, lean)● Hyperandrogen + PCO● Hyperandrogen + Anovulation● Anovulation + PCO● Hyperandrogen + PCO + Anovulation
Significance● 60% PCOS patients Obese in USA● 90-95% Anovulatory at fertility Clinics ● 3 x rate of miscarriage● 3x endometrial cancer● Cardiovascular DIsease & Diabetes
Lashen, (2010);Sirmans & Pate, (2013);McGowan, (2011).
Are the metabolic risk Factors due to PCOS or Obesity?
Are the metabolic risk Factors due to PCOS or Obesity?
?
DyslipidemiaInsulin ResistanceDiabetesGestational DiabetesHIgh blood PressureHeart Disease Chronic Inflammation
Are the metabolic risk Factors due to PCOS or Obesity?
DyslipidemiaInsulin ResistanceDiabetesGestational DiabetesHIgh blood PressureHeart Disease Chronic Inflammation
RISK IS INDEPENDENTOF OBESITY!
Are the metabolic risk Factors due to PCOS or Obesity?
DyslipidemiaInsulin ResistanceDiabetesGestational DiabetesHIgh blood PressureHeart Disease Chronic Inflammation
RISK IS INDEPENDENTOF OBESITY!
WHY???
Are the metabolic risk Factors due to PCOS or Obesity?
DyslipidemiaInsulin ResistanceDiabetesGestational DiabetesHIgh blood PressureHeart Disease Chronic Inflammation
RISK IS INDEPENDENTOF OBESITY!
INNATE INSULINRESISTANCE
WHAT IS INSULIN RESISTANCE?
Sirmans & Pate, (2014); Johnson, (2014).
How does insulin resistance effect PCOS?
Kilic et al,(2010)
Polycystic Ovaries: ● No dominant
follicle chosen● Follicles don’t
undergo cell death
Treatments studied:
MetforminStop Gluconeogenesis:Lower Glucose Levels
Decrease Insulin Production
(Genazzani et al, 2004).
Increase Production of Sex hormone Binding Globulin (SHBG)
MetforminStop Gluconeogenesis:Lower Glucose Levels
Decrease Insulin Production
(Genazzani et al, 2004).
Increase Production of Sex hormone Binding Globulin Hyperandrogenism
Ovulation
Oral Contraceptives● Great at creating Menstrual cyclicity &
Preventing Pregnancy● Decrease androgens (increase SHBG)● Decrease hirsutism in 80%● Decreased glucose tolerance● Increase chronic inflammation and BMI● Worsen dyslipidemia Morin-Papunen et al., (2003);Elter, Imir, & Durmusoglu, (2002).
Oral Contraceptives and Metformin● Reduction in:
○ Hyperandrogenism○ Waist: Hip○ BMI○ Pregnancy
Increases in:
○ Insulin Sensitivity○ SHBG Elter, Imir, & Durmusoglu, (2002)
Clomiphene Citrate● Antiestrogenic: normalizes FSH & LH● faster than metformin● Does not Decrease long term morbidity and Mortality risks
○ Ovarian hyperstimulation syndrome, multiple birth pregnancies & Endometrial thinning
○ Pregnancy rate increased 3.5X when used with metformin
Palomba et al., (2005).; Johnson, (2014)
Ovulation
Supplements: Inositol
Oner & Muderris, (2013).
Supplements: Inositol ● 1200 mg of D-chiro-inositol, ~ 2 months
○ Serum Androgen
○ Triglycerides
○ 86% Ovulated!
● 2-4g, Myo-Inositol
○ Oocyte quality
○ Ovulation
○ Dyslipidemia & Hyperandrogenism Nestler et al, (1999). & Unfer et al, (2012).
Hyperandrogenism Infrequent/Absent menses
Supplements: Vitamin D
Oner & Muderris, (2013).
Supplements: Vitamin D ● Deficiency common in PCOS Obese &
Nonobese● Insulin resistance is an independent
predictor of Deficiency● Increase [SHBG]
Velija-Ašimi, (2014).
Hyperandrogenism
Supplements: Omega-3
Oner & Muderris, (2013).
Supplements: Omega-3 1500 mg/day/6 months
● Hirsutism● BMI● LH ● Testosterone● SHBG Oner & Muderris, (2013).
Hyperandrogenism
In Vitro Fertilization & MEtformin● Decrease Ovarian Hyperstimulation
Syndrome: ovaries painful & swollen● Increase oocyte quality● Increase Embryo viability
Kumbak & Kahraman, (2009); Lashen, (2010)
Laparoscopic Ovarian DrillingBest Predictor Of Success:● BMI● Androgen Levels● Normal & Overweight
○ 81% Ovulation○ 57% pregnancy
*Lower Variables = Higher Success*Li, & Ledger, W.L., (2004)
Gestational Diabetes and Metformin
Diet & Exercise
McGowan, (2011) ; Parker, (2015).
Diet & Exercise
McGowan, (2011) ; Parker, (2015).
LOw carbohydrate Diets:○ HDL-c○ Triglycerides○ Systolic Blood Pressure○ Weight
Exercise○ Insulin○ Glucose○ Weight
Public Health Implications● Holistic Approach to health● Direct health Care costs > $4.36 billion (2005).
○ Diagnosis○ Treatment○ comorbidities
● 7 x suicide rates● Diabetes occurs in 40% < 50 years old● Persistence of Obesity
Parker, (2015); Caglar et al, (2013); McGowan, (2010).